Journal of the American Medical Informatics Association Volume 16
AMIA Board White Paper 䡲
Core Content for the Subspecialty of Clinical Informatics
REED M. GARDNER, PHD, J. MARC OVERHAGE, MD, PHD, ELAINE B. STEEN, MA,,
BENSON S. MUNGER, PHD, JOHN H. HOLMES, PHD, JEFFREY J. WILLIAMSON, DON E. DETMER, MD, MA,
FOR THE AMIA BOARD OF DIRECTORS
Abstract The Core Content for Clinical Informatics defines the boundaries of the discipline and informs
the Program Requirements for Fellowship Education in Clinical Informatics. The Core Content includes four major
categories: fundamentals, clinical decision making and care process improvement, health information systems, and
leadership and management of change. The AMIA Board of Directors approved the Core Content for Clinical
Informatics in November 2008.
䡲 J Am Med Inform Assoc. 2009;16:153–157. DOI 10.1197/jamia.M3045.
Background
The Core Content for a medical subspecialty defines the
boundaries of the discipline and informs the Program Re-
quirements for Fellowship Education. Program Require-
ments identify the knowledge and skills that must be
mastered through the course of fellowship training and
specify accreditation requirements for training programs.1
The American Board of Medical Specialties considers these
two documents along with other requirements and factors
when deciding whether to establish a new medical subspe-
cialty. The Core Content for Clinical Informatics is the result
of a two-year national development process initiated by the
American Medical Informatics Association and supported
Affiliations of the authors: Department of Medical Informatics,
University of Utah (RMG), Salt Lake City, UT; Regenstrief Institute
and Indiana Health Information Exchange (JMO), Indianapolis, IN;
American Medical Informatics Association (EBS, JJW, DED), Be-
thesda, MD; Arizona Emergency Medicine Research Center, Uni-
versity of Arizona (BSM), Tucson, AZ; Center for Clinical Epidemi-
ology and Biostatistics, University of Pennsylvania School of
Medicine (JHH), Philadelphia, PA; University of Virgina School of
Medicine (DED), Charlottesville, VA.
The American Medical Informatics Association (AMIA) Board of
Directors thanks the members of the Clinical Informatics Core
Content team for their thoughtful and energetic discussions that
resulted in this document. Team members included: Joan S. Ash,
PhD, MBA; James J. Cimino, MD; H. Dominic Covvey, MSc; Reed
M. Gardner (Chair), PhD; John H. Holmes, PhD; Nancy C. Nelson,
MS; J. Marc Overhage, MD, PhD (Vice Chair); Charles Safran, MS,
MD; Richard N. Shiffman, MD, MCIS; and Heiko Spallek, DMD,
PhD. AMIA acknowledges the contributions of over fifty reviewers
whose input strengthened the core content. AMIA thanks the
Robert Wood Johnson Foundation for generously supporting this
project.
Correspondence: Elaine B. Steen, MA, American Medical Informat-
ics Association, 4915 St. Elmo Avenue, Suite 401, Bethesda, MD
20814; e-mail: ⬍elainesteen@msn.com⬎.
Received for review: 10/21/2008; Accepted for publication:
12/05/2008
Number 2 March / April 2009 153
Perspectives
JAMIA on Informatics
by the Robert Wood Johnson Foundation.2 In November
2008, the AMIA Board of Directors approved both the Core
Content and Program Requirements for clinical informatics.
Definition and Description of the Subspecialty
Clinical informaticians transform health care by analyzing,
designing, implementing, and evaluating information and
communication systems that enhance individual and popula-
tion health outcomes, improve patient care, and strengthen the
clinician-patient relationship.
Clinical informaticians use their knowledge of patient care
combined with their understanding of informatics concepts,
methods, and tools to:
• assess information and knowledge needs of health care
professionals and patients,
• characterize, evaluate, and refine clinical processes,
• develop, implement, and refine clinical decision support
systems, and
• lead or participate in the procurement, customization,
development, implementation, management, evaluation,
and continuous improvement of clinical information
systems.
Physicians who are board-certified in clinical informatics
collaborate with other health care and information technol-
ogy professionals to promote patient care that is safe,
efficient, effective, timely, patient-centered, and equitable.
As illustrated in Figure 1, clinical informatics encompasses
three spheres of activity:
• clinical care (i.e., the provision of clinical services to an
individual patient),
• the health system (i.e., the structures, processes, and
incentives that shape the clinical care environment; this
includes major health domains such as public health,
population health, personal health, health professional
education, and clinical research, in addition to clinical
care),
154
F i g u r e 1. Domains of Clinical Informatics.
• information and communications technology (i.e., the
tools that enable the efficient capture, delivery, transmis-
sion, and use of data, information, and knowledge and
the knowledge of how to apply those tools effectively).
Clinical informaticians work at the intersection of these
three domains, and must demonstrate mastery of:
• medical knowledge,
• the field of informatics,
• the health care environment, including how business
processes influence health care delivery and the flow of
data among the major domains of the health system,
• how information systems and processes enhance or com-
promise the decision making and actions of health care
team members,
• re-engineering health care processes,
• fundamental information system concepts, including the
life cycle of information systems, the constantly evolving
capabilities of information technology and health care,
and the technical and nontechnical issues surrounding
system implementation,
• how clinical information systems impact users and pa-
tients, how to support clinician users, and how to pro-
mote clinician adoption of systems,
• evaluation of information systems to provide feedback
for system improvement,
• leadership in organizational change, fostering collabora-
tion, communicating effectively, and managing large
scale projects related to clinical information systems.
The core content for the subspecialty of clinical informatics
comprises four major categories that must be mastered.
Fundamentals
The first core content category comprises basic knowledge
that provides clinical informaticians with a common vocab-
ulary and understanding of the environment in which they
function.
Clinical informaticians draw from the broader field of bio-
medical and health informatics as they apply informatics
Gardner et al., Core Content for Clinical Informatics
methods, concepts, and tools to the practice of medicine.
Thus, they must understand the culture, boundaries, and
complexities of the field. Further, the stakeholders, struc-
tures, and processes that constitute the health system affect
the information and knowledge needs of health care profes-
sionals and influence the selection and implementation of
clinical information processes and systems. The flow of data,
information, and knowledge among the various domains of
the health system also creates important challenges for
clinical informaticians as many of the data used in public
health, personal health management, and clinical research
originate in the clinical domain and reside in clinical infor-
mation systems.
Clinical Decision Making and Care Process
Improvement
The second core content category comprises knowledge and
skills that enable a clinical informatician to implement
effective clinical decision making systems and participate in
the development of clinical processes that support effective,
efficient, safe, timely, and equitable patient-centered care.
A primary goal of clinical informaticians is to strengthen
clinical decision making by health care professionals and
patients and to support and improve clinical care processes.
This goal depends on implementing systems that support
clinical objectives and, when necessary, identifying changes
needed in clinical processes to take full advantage of clinical
information system capabilities.
A range of theoretical and practical issues must be ad-
dressed in the development and implementation of clinical
decision support tools. The cognitive and scientific under-
pinnings of medical decision making must be understood to
capitalize on information system capabilities in improving
clinical processes. Design of robust clinical information
systems and processes relies upon knowledge management
principles in acquiring, generating, representing, modeling,
and maintaining information to support clinical decision
making. Further, to achieve the full benefits of information
systems and processes, clinical informaticians must be able
to conceptualize improvements in clinical processes and
decision making and collaborate with their clinical col-
leagues as well as information technology professionals to
implement changes in the information systems and clinical
processes.
Health Information Systems
The third core content category comprises knowledge and
skills that enable a clinical informatician to participate in the
development or selection of an information system for
clinicians, prepare clinicians before implementation and
support them during implementation and ongoing opera-
tion of a clinical information system, and evaluate the
effectiveness of a system in meeting clinical needs.
Clinical informaticians need to assess the advantages and
disadvantages of various technological approaches and de-
termine the best fit for the clinical environment. They also
need a common vocabulary and shared knowledge base to
collaborate with information technology personnel. Since
the quality of clinical data directly affects the effectiveness of
information systems and clinical decision support tools as
well as the reliability of clinical research that depends on
those data, clinical informaticians work with interdiscipli-
Journal of the American Medical Informatics Association Volume 16 Number 2 March / April 2009 155

nary teams to ensure that the data used to make clinical 1.2. The Health System
decisions meet state-of-the-art standards. 1.2.1. Determinants of individual and population
Information systems are not limited to hardware and soft- health
ware; they include people, processes, and policies that 1.2.2. Primary domains, organizational structures,
support the use of the technology. Thus, clinical informati- cultures, and processes
cians must address these components as part of system 1.2.2.1. Health care delivery
analysis (planning) and implementation. System evaluation 1.2.2.2. Public health
is required to determine whether a clinical information 1.2.2.3. Clinical research
system is meeting its goals. Clinical informaticians need to 1.2.2.4. Education of health professionals
understand the full range of issues related to evaluation so 1.2.2.5. Personal health
1.2.3. The flow of data, information, and knowledge
that they can determine the appropriate evaluative methods
within the health system
and provide feedback for successful information system
1.2.4. Policy & regulatory framework
implementation and use.
1.2.5. Health economics and financing
There are myriad health information systems and these 1.2.6. Forces shaping health care delivery
systems are constantly evolving. Thus, the Core Content 1.2.7. Institute of Medicine quality components
identifies the common elements of health information sys- 1.2.7.1. Safety
tems used in different clinical settings and does not include 1.2.7.2. Effectiveness
an exhaustive list of clinical information systems. 1.2.7.3. Efficiency
Leadership and Management of Change 1.2.7.4. Patient-centeredness
The fourth core content category comprises knowledge and 1.2.7.5. Timeliness
skills that enable clinical informaticians to lead and manage 1.2.7.6. Equity
changes associated with the introduction and adoption of
2. Clinical Decision Making and Care Process Improve-
clinical information systems.
ment: The knowledge and skills that enable a clinical
Successful implementation of information systems requires informatician to implement effective clinical decision
behavioral, cultural, and social change within an organiza- making systems and participate in the development of
tion. Thus, clinical informaticians require knowledge and clinical processes that support effective, efficient, safe,
skills in understanding and analyzing organizational cul- timely, equitable, and patient-centered care.
ture, planning organizational change, building and working 2.1. Clinical Decision Support
in effective multidisciplinary teams, and leading informa- 2.1.1. The nature and cognitive aspects of human
tion system development and implementation. Clinical decision making
informaticians must be able to listen, understand needs, 2.1.1.1. General
articulate plans, explain rationales, inform constituents, re- 2.1.1.2. Medical
port results, and foster collaboration. They must relate 2.1.2. Decision science
clinical information system needs and plans to larger orga- 2.1.2.1. Decision analysis
nizational strategic goals and be proficient in project man- 2.1.2.2. Probability theory
agement to oversee the implementation of new systems and 2.1.2.3. Utility and preference assessment
processes. 2.1.2.4. Cost effectiveness analysis
2.1.2.5. Test characteristics (e.g., sensitivity,
Core Content specificity, predictive value)
1. Fundamentals: The basic knowledge that provides clini- 2.1.3. Application of clinical decision support
cal informaticians with a common vocabulary and under- 2.1.3.1. Types of decision support (e.g., alerts,
standing of the environment in which they function. reminders, prompts)
1.1. Clinical Informatics 2.1.3.2. Users of decision support (including
1.1.1. The discipline of informatics clinicians and patients)
1.1.1.1. Definitions of informatics 2.1.3.3. Implementing, evaluating, and main-
1.1.1.2. History of informatics (e.g., evolution taining decision support tools
2.1.4. Transformation of knowledge into clinical de-
of health records)
cision support tools
1.1.1.3. Domains/subspecialties of informat-
2.1.4.1. Knowledge generation
ics
2.1.4.2. Knowledge acquisition
1.1.1.4. Careers in informatics
2.1.4.3. Knowledge modeling
1.1.1.5. Professional organizations
2.1.4.4. Knowledge representation
1.1.1.6. Current and future challenges for
2.1.4.5. Knowledge management and
informatics
1.1.2. Key informatics concepts, models, and theo- maintenance
2.1.5. Legal, ethical, and regulatory issues
ries
2.1.6. Quality and safety issues
1.1.3. Clinical informatics literature
2.1.7. Supporting decisions for populations of pa-
1.1.3.1. Core literature
tients
1.1.3.2. Critical analysis of informatics literature
1.1.4. International clinical informatics practices 2.2. Evidence-based Patient Care
1.1.5. Ethics and professionalism 2.2.1. Evidence sources
1.1.6. Legal and regulatory issues 2.2.2. Evidence grading
156
2.2.3. Clinical guidelines
2.2.4. Implementation of guidelines as clinical algo-
rithms
2.2.5. Information retrieval and analysis
2.2.5.1. Search skills
2.2.5.2. Critical analysis of biomedical literature
2.3. Clinical Workflow Analysis, Process Redesign, and
Quality Improvement
2.3.1. Methods of workflow analysis
2.3.2. Principles of workflow re-engineering
2.3.3. Quality improvement principles and practices
3. Health Information Systems: The knowledge and skills
that enable a clinical informatician to participate in the
development or selection of an information system for
clinicians; prepare clinicians prior to implementation and
support them during implementation and ongoing oper-
ation of a clinical information system; and evaluate the
effectiveness of a system in meeting clinical needs.
3.1. Information Technology Systems
3.1.1. Computer Systems
3.1.1.1. Programming
3.1.1.2. Data and control structures
3.1.1.3. Software development methods (e.g.,
agile, waterfall, spiral, rapid prototyp-
ing)
3.1.1.4. System integration
3.1.1.5. Quality
3.1.1.6. Information systems design and analy-
sis (e.g., logical schema, normalization/
denormalization, process modeling)
3.1.2. Architecture
3.1.2.1. Systems (e.g., distributed, centralized,
relational, object oriented, warehouses/
data marts)
3.1.2.2. Networks
3.1.2.3. Data/database
3.1.3. Networks
3.1.3.1. Topologies
3.1.3.2. Telecommunications
3.1.4. Security
3.1.4.1. The HIPAA Security Rule and other
government regulations
3.1.4.2. Firewalls
3.1.4.3. Virtual private networks
3.1.4.4. Encryption
3.1.5. Data
3.1.5.1. Integrity
3.1.5.2. Mapping
3.1.5.3. Manipulation (e.g., querying, SQL, re-
porting)
3.1.5.4. Representation and types
3.1.5.5. Warehousing
3.1.5.6. Data mining and knowledge discovery
3.1.6. Technical approaches that enable sharing data
3.1.6.1. Integration versus interfacing
3.1.6.2. Dealing with multiple identifiers
3.1.6.3. Anonymization of data
Gardner et al., Core Content for Clinical Informatics
3.2. Human Factors Engineering
3.2.1. Models, theories, and practices of human-
computer (machine) interaction (HCI)
3.2.2. HCI Evaluation, usability testing, study de-
sign and methods
3.2.3. Interface design standards and design principles
3.2.4. Usability engineering
3.3. Health Information Systems and Applications
3.3.1. Types of functions offered by systems
3.3.2. Types of settings where systems are used
3.3.3. Electronic health/medical records systems as
the foundational tool
3.3.4. Telemedicine
3.4. Clinical Data Standards
3.4.1. Standards development history and current
process
3.4.2. Data standards and data sharing
3.4.3. Transaction standards
3.4.4. Messaging standards
3.4.5. Nomenclatures, vocabularies, and terminologies
3.4.6. Ontologies and taxonomies
3.4.7. Interoperability standards
3.5. Information System Lifecycle
3.5.1. Institutional governance of clinical informa-
tion systems
3.5.2. Clinical information needs analysis and sys-
tem selection
3.5.2.1. Methods for identifying clinician in-
formation system needs
3.5.2.2. Assessment of clinical process changes
that will be required
3.5.2.3. Elements of a system requirements
specification document (e.g., technical
specifications, intellectual property,
patents, copyright, licensing, contract-
ing, confidentiality, specific organiza-
tional needs such as user training and
support)
3.5.2.4. Risk analysis and mitigation
3.5.2.5. The costs of health information and
communications technologies
3.5.3. Clinical information system implementation
3.5.3.1. Elements of a system implementation
plan
3.5.3.2. Models of user training and support
processes that can meet clinician
needs
3.5.3.3. Processes and mechanisms that obtain
and respond to clinician feedback
3.5.4. Clinical information system testing, before,
during and after implementation
3.5.5. Clinical information system maintenance
3.5.5.1. Disaster recovery and downtime
3.5.5.2. Clinical information system transitions
and decommissioning of systems
3.5.6 Clinical information system evaluation
3.5.6.1. Outcomes relevant to the clinical goals
and quality measures
Journal of the American Medical Informatics Association Volume 16
3.5.6.2. Qualitative and quantitative methods for
evaluating clinical information systems
3.5.6.3. Evaluation plan design
4. Leading and Managing Change: The knowledge and
skills that enable clinical informaticians to lead and
manage changes associated with implementing clinical
information systems and promoting adoption by health
professionals.
4.1. Leadership Models, Processes, and Practices
4.1.1. Dimensions of effective leadership
4.1.2. Governance (e.g., processes; responsibility
versus authority)
4.1.3. Negotiation
4.1.4. Conflict management
4.1.5. Collaboration
4.1.6. Motivation
4.1.7. Decision making
4.2. Effective Interdisciplinary Teams
4.2.1. Human resources management (e.g., hiring,
performance reviews and feedback, profes-
sional development, termination)
4.2.2. Team productivity and effectiveness (e.g., ar-
ticulating team goals, defining rules of opera-
tion, clarifying individual roles)
4.2.3. Group management processes (e.g., nominal
group, consensus mapping, Delphi method)
4.2.4. Managing meetings
4.2.5. Managing group deliberations
References y
4.3. Effective Communications
4.3.1. Effective presentations to groups
4.3.2. Effective one-on-one communication
4.3.3. Writing effectively for various audiences and
goals
4.3.4. Developing effective communications pro-
gram to support system implementation
Number 2 March / April 2009 157
4.4. Project Management
4.4.1. Basic principles
4.4.2. Identifying resources
4.4.3. Resource allocation
4.4.4. Project management tools (non-software spe-
cific)
4.4.5. Informatics project challenges
4.4.5.1. Scope creep
4.4.5.2. Managing expectations
4.4.5.3. Balancing competing priorities
4.5. Strategic and Financial Planning for Clinical Infor-
mation Systems
4.5.1. Establishing mission and objectives
4.5.2. Environmental scanning
4.5.3. Strategy formulation
4.5.4. Action planning and strategy implementation
4.5.5. Capital and operating budgeting
4.5.6. Principles of managerial accounting
4.5.7. Evaluation of planning process
4.6. Change Management
4.6.1. Assessment of organizational culture and be-
havior
4.6.2. Change theories (e.g., precede-proceed, social
influence theories, complex adaptive systems)
4.6.3. Change management strategies
4.6.4. Strategies for promoting adoption and effec-
tive use of clinical information systems
1. Safran C, Shabot MM, Munger BS, Holmes JH, Steen EB,
Lumpkin JR, et al. Program Requirements for Fellowship Edu-
cation in the Subspecialty of Clinical Informatics. J Am Med
Informatics Assoc 2009;16:158-166.
2. Detmer DE, Lumpkin JR, Williamson JJ. Defining the Medical
Subspecialty of Clinical Informatics. J Am Med Informatics
Assoc 2009;16:167-168.